Author: Lisa Priest
Publisher: Doubleday Canada Limited, Toronto.
Copyright: 1998

Historically, accountability within Canada's healthcare system has essentially been a non-issue for a couple of reasons. Due to a lack of availability of healthcare information, consumers placed faith in their physicians and the healthcare system overall. Further, the system's robustness and growth masked any problems that may have existed. In other words, there were enough dollars in the system that healthcare executives could solve most problems simply by throwing money at them. Due to the massive reform movement within Canada's healthcare system in the 90s, however, many problems have since developed, while others which were masked, have surfaced. Poll after poll now shows that Canadians are increasingly worried that their healthcare system may be at risk. Concern over the state of the healthcare system, increased availability of healthcare information, especially on the Internet, and an overwhelming focus on healthcare issues in the media have produced more savvy consumers who demand to know more about their healthcare system. Accountability is something the healthcare system can no longer avoid.

In her controversial book, "Operating in the Dark: The Accountability Crisis in Canada's Healthcare System," Toronto Star healthcare reporter, Lisa Priest explores, in a somewhat sensationalist fashion, how lack of information can harm patients and their families. Ms. Priest states in her acknowledgments that the research into her 318-page book, written for the average healthcare consumer in lay terms, began with a simple question, "Why can't I find out how good my hospitals and doctors are?" With the help of the 1996-97 Atkinson Fellowship in Public Policy, Ms. Priest traveled to England, the U.S., and across Canada to explore the issue of accountability, or the lack thereof, in healthcare systems. The first product of this research was a series of articles in the Toronto Star in the Fall of 1997, entitled "Operating in the Dark." As expected, this series drew a variety of impassioned responses, which spurred Ms. Priest to develop her research into a full-length book, the subject of this review.

Ms. Priest begins with an alarmist chapter entitled, "Tragedy by the Dozen," describing in horrific detail the experiences of a number of parents whose children died during 1994 in a paediatric cardiac program at the Health Sciences Center (HSC) in Winnipeg, Manitoba. She describes how the death rate for the program rose in 1994 to 29% for children under the age of one (yet, we are not told what the death rate at the hospital was previous to that year). A subsequent inquiry by a team from Toronto's Hospital for Sick Children reported this as an unacceptable rate and far in excess of the 11% rate at The Hospital for Sick Children. The inquiry also found that the volume of cases at the program was not sufficient to maintain the skill level of the operating-room team. As a result, the program was indefinitely suspended in February of 1995.

Ms. Priest highlights a number of issues from this case study. First, there should be sufficient volumes of cases to warrant the establishment of surgical programs and in order to maintain the skill level of operating room teams. This is an issue particularly in areas with scattered populations. Another is that rigorous assessment combined with appropriate mentorship and monitoring of new physicians is not routine practice in most hospitals. Third, surgical programs should be monitored on an ongoing basis to ensure timely identification and remediation of problems and, finally, the results of such monitoring should be made public so that consumers can make informed choices.

Ms. Priest provides a useful and practical checklist of questions that patients and family members should ask of their surgeon. These include:

• How experienced are you at this surgery?
  
• What are the death and complications rates for this procedure at the hospital, for you individually, and for other hospitals?
  
• How many of these operations have you performed unassisted?

She also describes how healthcare consumers can lobby their provincial and federal governments to ensure that high-risk surgeries are done only in hospitals with enough volume to support skill sets and to ensure that surgical programs are monitored routinely.

This sensationalist first chapter gives way to nine subsequent chapters dealing with issues that range from setting up hot-lines in order to find out about physicians' pasts to establishing the equivalent of Britain's Patient's Charter in Canada.

In chapter three, for example, Ms. Priest describes a 1-800 consumer service line in Massachusetts where consumers can find out whether a doctor has settled out of court, been found negligent in a malpractice suit, or has a previous criminal conviction. Ms. Priest argues that in Canada many hospitals do not thoroughly check physicians' records before hiring them. Once hired, it is often difficult to revoke or suspend the privileges of physicians who are providing substandard care. She also demonstrates that there is no mechanism for routinely tracking and acting on findings of negligence in malpractice cases. In the absence of such screening and monitoring mechanisms, Ms. Priest advocates a state-mandated, toll-free line to allow Canadians to check-up on physicians.

In a subsequent chapter, Ms. Priest advocates a Patient's Charter in Canada, similar to the one in Britain. In 1994, under the leadership of then Prime Minister John Major, Britain began tracking and publishing waiting times for 59 different areas of the healthcare system. Among others, these include waiting times for emergency room care, for hip replacement surgery, and for cardiac operations. This government initiative culminates each year in the publication of hospital report cards in England, Scotland, and Wales. Ms. Priest points out that the establishment of such charters has been attempted in Canada, specifically in Ontario and Alberta, but has not been successful due to political reasons.

Until recently, accountability has not been a high priority within our healthcare system, thus mechanisms for routine and accurate data collection have yet to be perfected. In recent years, however, there have been many efforts to improve data collection and the reporting of healthcare statistics. For example, the Ontario Hospital Association recently released the Hospital Report '98 comparing five regions across Ontario on a variety of measures. Similarly, Toronto's teaching hospitals recently published Performance '98, comparing themselves to each other on a number of measures such as patient satisfaction. Despite these efforts, it will take time and a great deal of financial investment from governments and hospitals before data quality is at the point where the healthcare system can report the kinds of measures Ms. Priest advocates.

Having said this, one of the strengths of Ms. Priest's book is her list of practical questions and suggestions she provides at the end of each chapter which consumers can use to obtain more information and to lobby the government for changes. The greatest strength of her book, however, lies in its ability to provoke and spark debate on the topic of healthcare accountability. Albeit, the way in which she does this is unbalanced and misleading for the average consumer who may not be aware of the broader context surrounding issues of accountability.

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